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Post‐procedural considerations

Care planning

The purpose of collecting information through the process of assessment is to enable the nurse to make a series of clinical judgements (which are known in some circumstances as nursing diagnoses), and subsequently decisions about the nursing care each individual needs. Nursing diagnoses provide a focus for planning and implementing effective and evidence‐based care. This process consists of identifying nursing‐sensitive patient outcomes and determining appropriate interventions (Alfaro‐LeFevre [3], Shaw [78], White [90]). The key steps are:
  • To determine the immediate priorities and recognize whether the patient's problems require nursing care or whether a referral should be made to someone else.
  • To identify the anticipated outcome for the patient, noting what the patient will be able to do and within what time frame. The use of ‘measurable’ verbs that describe patient behaviour or what the patient says facilitates the evaluation of patient outcomes (Box 2.4).
  • To determine the nursing interventions – that is, what nursing actions will prevent or manage the patient's problems so that the patient's outcomes may be achieved.
  • To record the care plan for the patient, which may be written or individualized from a standardized (sometimes called ‘core’) care plan or a computerized care plan.
Outcomes should be patient focused and realistic, stating how the outcomes or goals are to be achieved and when the outcomes should be evaluated. Outcomes may be short, intermediate or long term, enabling the nurse to identify the patient's health status and progress (stability, improvement or deterioration) over time. Setting realistic outcomes and interventions requires the nurse to distinguish between nursing diagnoses that are life threatening or an immediate risk to the patient's safety, and those that may be dealt with at a later stage.
Box 2.4
Examples of measurable and non‐measurable verbs for use in outcome statements

Measurable verbs (use these to be specific)

  • state, verbalize, communicate, list, describe, identify
  • demonstrate, perform
  • will lose, will gain, has an absence of
  • walk, stand, sit

Non‐measurable verbs (do not use)

  • know
  • understand
  • think
  • feel
Source: Reproduced from Alfaro‐LeFevre ([3]) with permission of Lippincott Williams & Wilkins.
It is important to continue to assess the patient on an ongoing basis while implementing the care planned. Assessing the patient's current status prior to implementing care will enable the nurse to check whether the patient has developed any new problems that require immediate action. During and after any nursing intervention, the nurse should assess and reassess the patient's response to care. The nurse will then be able to determine whether changes to the patient's care plan should be made immediately or at a later stage. If there are any patient care needs that require immediate action – for example, consultation or referral to a doctor – recording the actions taken is essential. Involving the patient and their family or friends will promote the patient's wellbeing and self‐care abilities. The use of clinical documentation in the nursing shift report, or ‘handover’, will help to ensure that the care plans are up to date and relevant (Alfaro‐LeFevre [3], White [90]).

Evaluating care

Effective evaluation of care requires the nurse to critically analyse the patient's health status to determine whether the patient's condition is stable, has deteriorated or has improved. Seeking the patient's and their family's views in the evaluation process will facilitate decision making. By evaluating the patient's outcomes, the nurse is able to decide whether changes need to be made to the care planned. Evaluation of care should take place in a structured manner and on a regular basis by a registered nurse.

Documentation

Nurses have a professional responsibility to ensure that healthcare records provide an accurate account of treatment, care planning and delivery, and are viewed as a tool of communication within the team. There should be clear evidence of the care planned, the decisions made, the care delivered and the information shared (NMC [55]) (Box 2.5). The content and quality of record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC [55]).
Box 2.5
The Royal Marsden NHS Trust's guidelines for nursing documentation (2011) (adopted in line with NMC [55])

General principles

  1. Records should be written legibly in black ink in such a way that they cannot be erased and are readable when photocopied.
  2. Entries should be factual, consistent, accurate and not contain jargon, abbreviations or meaningless phrases (e.g. ‘observations fine’).
  3. Each entry must include the date and time (using the 24‐hour clock).
  4. Each entry must be followed by a signature and the name printed as well as:
    • the job role (e.g. staff nurse or clinical nurse specialist);
    • if a nurse is a temporary employee (i.e. an agency nurse), the name of the agency.
  5. If an error is made, this should be scored out with a single line and the correction written alongside with date, time and initials. Correction fluid should not be used at any time.
  6. All assessments and entries made by student nurses must be countersigned by a registered nurse.
  7. Healthcare assistants:
    • can write on fluid balance and food intake charts;
    • must not write on prescription charts, assessment sheets or care plans.

Assessment and care planning

  1. The first written assessment and the identification of the patient's immediate needs must begin within 4 hours of admission. This must include any allergies or infection risks of the patient and the contact details of the next of kin.
  2. The following must be completed within 24 hours of admission and updated as appropriate:
    • nutritional, oral, pressure ulcer and manual handling risk assessments;
    • other relevant assessment tools, for example pain and wound assessment.
  3. All sections of the nursing admission assessment must be completed at some point during the patient's hospital stay along with the identification of the patient's care needs. If it is not relevant or if it is inappropriate to assess certain functional health patterns (e.g. if the patient is unconscious) then the reasons should be indicated accordingly. The ongoing nursing assessment should identify whether the patient's condition is stable, has deteriorated or has improved.
  4. Wherever possible, care plans should be written with the involvement of the patient, in terms that they can understand, and include:
    • patient‐focused, measurable, realistic and achievable goals;
    • nursing interventions reflecting best practice;
    • relevant core care plans that are individualized, signed, dated and timed.
  5. Update the care plan with altered or additional interventions as appropriate.
  6. The nursing documentation must be referred to at shift handover so it needs to be kept up to date.

Principles of assessment

  1. Assessment should be a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire [37]).
  2. Assessment should be seen as a continuous process (Cancer Action Team [14]).

Structure of assessment

  1. The structure of a patient assessment should take into consideration the speciality and care setting and also the purpose of the assessment.
  2. Functional health patterns provide a comprehensive framework for assessment, which can be adapted for use within a variety of clinical specialities and care settings (Gordon [34]).

Methods of assessment

  1. Methods of assessment should elicit both subjective and objective assessment data.
  2. An assessment interview must be well structured and progress logically in order to facilitate the nurse's thinking and to make the patient feel comfortable in telling their story.
  3. Specific assessment tools should be used, where appropriate, to enable nurses to monitor particular aspects of care, such as symptom management (e.g. pain, fatigue), over time. This will help the nurse to evaluate the effectiveness of nursing interventions and it also often provides an opportunity for patients to become more involved in their care (O'Connor and Eggert [56]).

Decision making and nursing diagnosis

  1. Nurses should be encouraged to provide a rationale for their clinical judgements and decision making within their clinical practice (NMC [55]).
  2. The language of nursing diagnosis is a tool that can be used to make clinical judgements more explicit and enable more consistent communication and documentation of nursing care (Clark [15], Westbrook [89]).

Planning and implementing care

  1. When planning care, it is vital that nurses recognize whether patient problems require nursing care or whether a referral should be made to someone else.
  2. When a nursing diagnosis has been made, the anticipated outcome for the patient must be identified in a manner that is specific, achievable and measurable (NMC [55]).
  3. Nursing interventions should be determined with the aim of addressing the nursing diagnosis and achieving the desired outcomes (Gordon [34]).

Evaluating care

  1. Nursing care should be evaluated using measurable outcomes on a regular basis with interventions adjusted accordingly.
  2. Progress towards achieving outcomes should be recorded in a concise and precise manner. Using a method such as charting by exception can facilitate this (Murphy [52]).

Documenting and communicating care

  1. The content and quality of record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC [55]).
  2. In addition to the written record of care, the important role that the handover plays in the communication and continuation of patient care should be considered, particularly when considering the role of electronic records.
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